Brian L. Cook

Generalized anxiety disorder vs. panic disorder. Distinguishing characteristics and patterns of comorbidity.

In order to examine the validity of the distinction between generalized anxiety disorder (GAD) and panic disorder (PD) we compared 41 subjects with GAD and 71 subjects with PD. The GAD subjects had never had panic attacks. In contrast to the symptom profile in PD subjects suggestive of autonomic hyperactivity, GAD subjects had a symptom pattern indicative of central nervous system hyperarousal. Also, subjects with GAD had an earlier, more gradual onset of illness. In terms of coexisting syndromes, GAD subjects more often had simple phobias, whereas PD subjects more commonly reported depersonalization and agoraphobia. GAD subjects more frequently had first-degree relatives with GAD, whereas PD subjects more frequently had relatives with PD. A variety of measures indicated that our GAD subjects had a milder illness than those with PD. Also, fewer GAD subjects gave histories of major depression than did PD subjects. Among GAD subjects, coexisting major depression was associated with simple phobia and thyroid disorders and among PD subjects, comorbid depression was associated with social phobia and hypertension. Our findings indicate that the separation of GAD from PD is a valid one. They also indicate that, within disorders, unique patterns of comorbidity may exist that are important both clinically and theoretically.

Failure to differentiate bipolar disorder from schizophrenia on measures of neuropsychological function

30 inpatients diagnosed with schizophrenia were compared to 35 inpatients with bipolar affective disorder, manic type, on a large group of neuropsychological measures. Separate factor analyses were performed on measures of verbal, spatial, and speed variables in order to generate summary scales. Controlling for the effects of age, education, sex, duration of illness, number of previous hospitalizations, and medications at time of testing, there were no significant differences between diagnostic groups on the three factors or on individual test variables. Patients on medication performed more poorly on speed variables than those off medication. These findings call into question the notion of differential patterns of cognitive deficit among psychotic diagnoses.

Loss of the CD5+ and CD45RAhi B cell subsets in alcoholics

Chronic alcoholics are frequently immunodeficient, have polyclonal hypergammaglobulinaemia, and often have autoantibodies. Recent work in other diseases has shown that functional distinctions of possible relevance to autoimmunity and immunodeficiency can be found among the B cell subsets defined by differential expression of the surface markers CD5 and CD45RA. Therefore, we have evaluated the CD5,CD45RA B cell subsets of both chronic alcoholics without evidence of active liver disease (AWLD), and alcoholics admitted for acute alcoholic liver disease (ALD). Mean B cell numbers were normal in AWLD, but significantly reduced in ALD. Analysis of B cells by three‐colour flow cytometry in 20 patients and 29 controls revealed a sharp decrease in the percentage of alcoholics’ B cells which were CD5+, 37.6% versus 16.3%, P<0.00001; absolute CD5+ B cell numbers were similarly reduced (58.9 cells/μl versus 20.9; P=0.0012). In addition to the loss of CD5+ B cells, there was a reduction in the percentage of B cells which are CD5−CD45RAhi, leaving many patients with a B cell profile which was predominantly CD19+CD5−CD45RAlo. This subset appears phenotypically similar to the IgM‐producing CD5−CD45RAlo subset described by others, and may be enriched for autoantibody‐producing cells. One outlier patient was an ALD with 61% of B cells which were CD5+, which also is a profile consistent with increased autoantibody production.

Follow-up study of patients with panic disorder and agoraphobia with panic attacks treated with tricyclic antidepressants

One hundred and seven patients with panic disorder or agoraphobia with panic attacks were studied 1-4 years after treatment with a tricyclic antidepressant. At follow-up more than 80% of the patients remained symptomatic but fewer than half were experiencing panic attacks and only 40% were avoiding phobic situations. Although patients with agoraphobia were more severely ill and had been ill longer than those with panic disorder, their response to tricyclics and eventual outcome was similar to that for patients with panic disorder. Panic and agoraphobic patients who had the most severe symptoms initially showed the least improvement. The results suggest that panic disorder and agoraphobia with panic attacks are variants of a single illness and that, despite its chronicity, this illness has a favorable outcome.

Reduction of Gastrointestinal Symptoms Following Treatment for Panic Disorder

Symptoms of gastrointestinal distress, including those of irritable bowel syndrome, were reported more frequently by patients with panic disorder than by nonanxious controls. Five of 30 subjects with panic disorder met criteria for irritable bowel syndrome, the onset of which coincided with the onset of panic disorder. Effective treatment for the anxiety disorder was accompanied by a reduction in gastrointestinal symptoms in all subjects.

A Review of Carbamazepine's Hematologic Reactions and Monitoring Recommendations

Early case reports of fatal hematologic effects attributed to carbamazepine (CBZ) resulted in extensive monitoring recommendations by the manufacturer. The rarity of blood dyscrasias led many authors to question the manufacturers guidelines. Thus the manufacturer removed specific monitoring guidelines, allowing physicians to monitor CBZ using their clinical judgment. This article reviews case reports and studies of CBZs hematologic effects. Due to their rapid onset, daily laboratory checks would be necessary to monitor for aplastic anemia, agranulocytosis, and thrombocytopenia. These adverse effects are best monitored by informing patients and physicians to carefully watch for signs and symptoms. Leukopenia develops more slowly, occurring in approximately 12 percent of children and 7 percent of adults. Its onset is typically within the first three months of treatment, with patients at risk having a low or low-normal pretreatment white blood cell (WBC) count. Leukopenia often reverses, even if CBZ is continued. Based upon our review of the literature, we recommend monitoring of those high-risk patients during the first three months of treatment with the frequency being determined by results of each laboratory value. WBC counts <3000/mm3 or neutrophil counts below 1000/mm3 warrant a decrease in dose with frequent monitoring or CBZ discontinuation, if necessary.

Anxiety and the menstrual cycle in panic disorder

Nineteen females with panic disorder were studied using daily prospective home diary ratings of various general health related items, a short anxiety self-rating scale, a survey of late luteal phase dysphoric symptoms, as well as a record of the number and severity of panic attacks. The subjects collected information for 60 consecutive days, and information regarding 30 menstrual cycles was available for analysis. Overall, subjects retrospectively reported increases in their anxiety symptoms during premenstrual days, but this was not demonstrated consistently on daily prospective ratings.

The military environment: Risk factors for women's non-fatal assaults

Little is known regarding environmental exposures for non-fatal violence toward women in the workplace. We sought to identify factors associated with non-fatal physical assault occurring to women during military service. A cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service was conducted; 537 women were interviewed. Twenty-three percent experienced non-fatal physical assault during military service. Rates of assault were consistent across eras of service. Military environmental exposures, including sexual harassment allowed by officers (P < 0.0001) and unwanted sexual advances while on duty (P < .0001) and in sleeping quarters (P < 0.0001), were independent risk factors for assault. Environmental factors in the military workplace, including leadership behavior, appeared to promote violence toward military women. Such occupational factors can be identified and should be eliminated.

The occurrence of a prodrome of generalized anxiety in panic disorder.

Twenty-eight percent of 32 panic disordered patients had a prodrome of generalized anxiety symptoms lasting a median of 5 years before the occurrence of their first panic attack. Patients with a generalized anxiety prodrome were similar to the nonprodrome patients for 55 tested clinical variables, including individual anxiety symptoms, response to treatment, severity of illness, and most aspects of family history. It appears that a prodrome of generalized anxiety symptoms is a variation of the presentation of panic disorder. Initially, these patients may be misdiagnosed as having generalized anxiety disorder (GAD) and contribute to the heterogeneity of GAD.

EEG abnormalities in bipolar affective disorder.

Forty-six patients with bipolar illness were evaluated with scalp-recorded electroencephalograms. Familial pattern of psychopathology was evaluated between groups with clinically normal and abnormal EEG tracings. Those with abnormal EEGs were noted to have a significantly negative family history of affective disorder when compared to the EEG normal group. These results may support the concept of some patients with mania having an acquired illness which occurs independent from its genetic loading.